Acquire Student ID#

Student Type*

First Name*

Middle Name

Last Name*

Address*

Address 2

City*

State*

Zip Code*

Home Phone*

( ) -

Mobile Phone*

( ) -

Please provide either a Home or Mobile phone number

E-mail Address *

Social Security Number*

Date of Birth*

Who is your current employer? *
If you're not sure if your employer is a Member Contractor,
choose the Employed By Member option, then enter the Company Verification Code.
If your company verification code is invalid,
then choose Employed by a Non-Member and type in the Company's name.

Please choose one of the options below

	Employed By Member Company Verification Code*
	Employed By a Non-Member Company Name & Phone*
	Unemployed

By submitting this form, I:
(1) I certify under penalty of perjury that all statements and information above are true and correct.
(2) If "YES" is selected in the "Are you currently employed by a IEC Chesapeake Member" field, I certify under penalty of perjury that the student being registered is employed by a IEC Chesapeake Member Contractor at the time registration is submitted. Any students found in violation of item (2) will be subject to expulsion without refund.

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